Legal Review & Commentary

ED treatment delayed — 14-year-old could have been saved by surgery, family claims

By Leslie E. Mathews, Esq., MHA

Buchanan Ingersoll & Rooney

Tampa, FL

Suzanne Gruszka, RN, MAS, CLNC, LHRM

Administrator, Clinical Support Services

Health Central

Ocoee, FL

News: A 14-year-old boy was taken to a local hospital emergency department (ED) with complaints of sharp pain on the right side of his face and his right shoulder after being kicked in the head by his mother. The boy reported that his pain level was 10 on a scale of 1-10; however, the triage nurse indicated his was a "non-urgent" case. The patient reportedly vomited more than once, continued to demonstrate signs of discomfort per his family, and had visible swelling of the neck and upper chest. The patient's heart rate continued to rise as time went on, and a soft tissue x-ray revealed "a lot of soft tissue swelling pushing the trachea out of position."

After several delays, the ED physician consulted vascular and thoracic surgeons; however, the surgeons recommended transferring the patient to a level 1 trauma center. Before he could be transferred, the patient heart rate plummeted, and he bled out into his chest. Surgeons could not save the patient's life. He went into cardiac arrest and died on the operating room table. The patient's family members sued the hospital and physicians. They claimed the doctor's negligence delayed surgery that could have saved the patient's life. The jury awarded the patient's family $2.4 million in malpractice damages.

Background: A 14-year-old boy, who was kicked in the head and neck area by his mother, presented to the ED with severe pain and swelling in his neck in August 2003. Despite a pain level of 10 and vomiting, nurses in the ED determined that the boy's case was "non-urgent."

The ED physician evaluated the patient and admitted being "baffled by the lack of bruising or associated injuries." The physician's examination revealed significant swelling, stable vital signs, a "comfortable" patient, and a small hemorrhage in the white of one eye. He ordered a soft-tissue X-ray to determine the cause of swelling. After an hour had passed and the patient vomited again, the physician reviewed the X-ray, which revealed soft tissue swelling pushing on the trachea. The physician then consulted a head and neck surgeon, gave the teen morphine for pain, and ordered a CT scan.

As time passed, the patient's condition worsened, and his heart rate began to rise. A radiologist read some of the CT scans from home, reporting the patient might have a "jugular injury with venous hemorrhage," and left her home to attend a wake before reading all of the scans. Several hours after his admission to the ED, the patient's blood work was ordered and revealed that he had lost two or more pints of blood. Eventually the radiologist read the entire CT and amended her report indicating that one of the patient's arteries was bleeding.

Upon seeing the result of the CT scan and just prior to finishing his shift at the hospital, the physician consulted vascular and thoracic surgeons. The vascular surgeon did not have the training to treat the patient. She recommended a thoracic surgery consult, and the thoracic surgeon did not come to the hospital or return calls for more than an hour. When the thoracic surgeon eventually evaluated the patient, he determined the patient should be transferred to a level 1 trauma center for treatment by a pediatric thoracic surgeon.

Just after the patient's father gave permission to transfer him, his condition worsened. His pain level shot up, and he began to scream. A short time later, his heart rate plummeted, and he bled out into his chest. The thoracic surgeon attempted to save his life; however, the bleeding was too great to control, and the patient died on the operating table.

The plaintiff and the defendants provided conflicting expert testimony attempting to convince the jury of whether treating the patient's injuries in a timely manner could have saved his life. The plaintiff's expert testified that blood was the only thing that could cause this kind of swelling and the patient's situation was a "major emergency." The expert testified that the ED physician should have ordered blood pressure monitoring, blood work, a CT scan, and vascular surgery right away. The defendant's experts testified that the injury was unusually rare and difficult to diagnose, and that the physician's treatment of the patient was appropriate. The defendant also presented testimony that even if the patient's injuries had been treated sooner, his condition was so grave and complex that the early treatment would not have changed the outcome.

The jury found that the physician's delay in appropriately treating the patient resulted in the patient's death and awarded the family $2.4 million. The defendant appealed; however, the appellate court found that the jury was capable of finding the physician's failure to adhere to the standard of care caused delays in treatment that could have saved his life.

Commentary: This case is a delay in diagnosis and treatment of a 14-year old patient who suffered from blunt neck trauma. There are few emergencies that pose such a challenge as neck trauma. The wounds or injuries might not manifest with clear signs and symptoms, and these potentially lethal injuries can be easily overlooked. The most significant risk is airway occlusion and exsanguinating hemorrhage. Direct force can shear the vasculature. The impact to the anterior aspect of the neck might crush the larynx or trachea.

Of all serious traumatic injuries, neck trauma accounts for 5-10%. About 3,500 people die annually. Neck trauma is more common in adolescent males. Arterial injuries are the major source of morbidity and mortality. About 7% of injuries to critical structures of the neck involve major arterial structures, including the subclavian, internal and external, and common carotid arteries.

The clinical symptoms range from patients who have no symptoms to those that have life-threatening airway obstruction or shock. A progressive airway obstruction can occur from an expanding hematoma, and the patient often presents with abnormal respiratory patterns, tachypnea, and cyanosis. The evaluation of blunt neck trauma begins with the assessment of the airway.

The clinical management of a patient with blunt neck trauma begins with the ED physician and staff assessing and securing the patient's airway. This process might include intubating the patient. Once the airway is secured, then X-rays of the neck and chest followed by a CT of the head, neck and chest would be recommended. Blunt neck trauma can cause vascular injuries that result in the formation of pseudoaneurysm, dissection, arteriovenous fistula, complete transaction, and thrombus formation. Use of a CT or CT angiogram to identify these formations is preferred.

The challenge for ED physicians is to detect the subtle but significant injuries that require intervention. This group includes patients who appear to have no immediate indication for surgical intervention. Blunt vascular injuries to the carotid or the vertebral arteries are rare, and clinical presentation is often subtle and nonspecific. The patient in this case presented with pain on the right side of his face and right shoulder. He had visible swelling of the neck and upper chest, and his X-ray of that area revealed "a lot of soft tissue swelling pushing the trachea out of position." This is a medical emergency, and his airway was compromised. There is no mention that his airway was managed by intubation.

The ED physician noted that there was significant swelling in the area and that he had stable vital signs. The patient reported vomiting several times at home, and he is noted to have vomited once in the ED. The ED physician did order a CT scan, as well as a consult with a head and neck surgeon. The physician also administered morphine for pain. This use of morphine might be questionable in a patient with decreased respiratory function.

It appears that the radiologist read a portion of the CT scans and reported that the patient might have a "jugular injury with venous hemorrhage." It is unclear whether that information was communicated to the ED physician prior to the radiologist leaving to attend a wake. Ordinarily when an abnormal result is identified, the radiologist contacts the ordering physician immediately. Such communication might have had an impact on the outcome of this patient. The case information states that the radiologist eventually returns to the report of the CT scan and amends it to indicate that one of the patient's arteries is bleeding. It is at this point that additional consultants are called; however, the patient's condition rapidly deteriorates.

There appears to be a real communication issue with this case from the time the patient presents through the time when he expires. There is no sense of urgency with the healthcare providers. While the patient demonstrated significant signs of a potential life-threatening injury, the assessment, diagnosis, and treatment of his injures were treated as "routine."

The Joint Commission has identified communication as the number three most frequently identified root cause of sentinel events for 2009, 2010, and 2011. Since 2004, communication has been the number one root cause for delays in treatment, followed by assessment as the number two root cause for delay in treatment. Of the most frequently reported sentinel event categories, delay in treatment has been number two for 2009 and 2010. The data shows a rapid increase in delay in treatment events since 2000. The Joint Commission released a Sentinel Event Alert (http://bit.ly/iglWsH) in 2002 identifying this as a serious issue especially for hospital EDs.

This patient's outcome might have been a positive one if he were triaged and treated in a more timely and emergent manner. The delay in treatment severely impacted his chances at survival.

REFERENCE

Superior Court of New Jersey, Appellate Division, Docket No. A-5330-07T15330-07T1